home email us! sindicaci;ón

Does “Prevention” Save Money?

by Scott MacStravic

The federal government and various “think tanks” it has hired have consistently found mixed results when asking the question: “Does Disease Management Work?”.  This has always been a ridiculous question to ask, since DM is not a single “treatment” whose efficacy can possibly be gauged in the way that particular drugs or medical treatments can.  DM is a wide range of different approaches, delivered by a wide range of different providers to a wide range of different patients with a wide range of different diseases.

A recent newspaper article attempted to ask and answer a similar question about “preventive medicine”, which includes DM, but goes far beyond that already broad and mixed bag of interventions.  It comes up with a number of arguments, though no data, to conclude that “prevention” will not save money, once its costs are factored in, and certainly will not save enough in terms of total sickness care costs to enable the country to finance insurance coverage for the currently uninsured. [D. Leonhardt “Free Lunch on Health? Think Again”, New York Times Aug 8, 2007]

It notes that the current “system” does not pay providers to keep people healthy, in fact perversely adds to sickness care costs by paying only for treating them once they are sick.  It concludes that studies usually find that prevention makes people healthier, but costs money, not saves it, overall.  After all, physicians and nurses have to spend time to get people to change their behaviors to healthier options.  Moreover, they are likely to be dealing with those who have not been persuaded to adopt and maintain healthy lifestyles through current services and strategies, so they are likely to be the toughest and most expensive to “reform” now.

The author cists a Stanford University School of Medicine study that estimates an anti-obesity program would have to treat five people, with interventions that are not cheap, to prevent just one new case of diabetes.  Prevention has to invest in interventions that will not have any meaningful impact on many of its participants, since they would not have become sick, anyway, while others do so in spite of participation.  Moreover, prevention increases the lifespan of population, and people contract more sickness as they get older, so lifetime sickness costs end up being increased.

In effect, because we have to “treat” many more times as many people through prevention as would have to be treated for sickness in order to prevent sickness, the costs of continuously treating those who would not have become sick overwhelms the savings produced by preventing the few cases of sickness that would have resulted.  The article concludes that: “Preventive care saves real money only when it replaces existing care that is expensive and doesn’t do much if any good.”  And it notes that as long as patients think the care they get will do them good, which they must or otherwise they wouldn’t get it, even preventing such “futile” care is a difficult task.

It quotes Jonathan Gruber, an MIT economist, as saying: “…if you’re going to control healthcare costs, it involves denying people care they want – or things they’ve been trained to think they want.”  Somehow,
”prevention” is equal to “rationing” as defined by the article.  But this is simply a “straw man” definition, as is defining prevention as a kind of medical care requiring the expensive services of physicians and nurses, in the same way as sickness care does.  In effect, the argument is that prevention would simply change what expensive providers do for patients, but still cost as much as treating sickness.

But the article ignores a host of preventive strategies and tactics, and a wide range of interventions, that do not require the use of physicians and nurses at all.  And it ignores the growing accuracy of preventive modeling in terms of identifying which people currently at risk represent sufficient risk/reward potential to warrant which kinds and costs of preventive interventions.  Both predictive and preventive technologies are improving dramatically, and both can often be applied on a population-wide basis, rather than the traditional one-to-one physician or nurse visit.

Predictive models can analyze collections of data on past sickness care claims, individual attitudes and behaviors, personality factors and perceptions, as well as on worker productivity and performance, to identify the risk/reward potential of individuals with increasing accuracy.  Individualized interventions aimed at multiple risk behaviors or conditions, or at preventing the emergence of such behaviors or conditions, can be generated automatically by computers, and communicated online of via mail for ten or twenty dollars a year per participant.

By tailoring prevention strategy and tactics to accurately predicted risk/reward potential and individual receptivity, and doing so inexpensively where necessary, plus intensively where justified, “prevention” can be as cost-effective as it needs to be in order to achieve its intended results.  And when it is applied to workforces, its benefits are often two to five times as great as the value of reduced sickness care costs.  Moreover, if it is applied to the young, it can deliver benefits over a lifetime, not just in the short run.

It is impossible to say that prevention does work, just as it is impossible to say that it does not.  “Prevention” is simply too vast an array of different challenges involving different people and intervention modes plus costs to come to any overarching conclusion.  But that is the point, after all – it is simply a silly question to attempt to answer simplistically and finally.  There have been thousands of successful applications reported, and perhaps as many unsuccessful attempts made but not reported, since failure rarely prompts as frequent and as loud reporting as does success.

We are ill-served by attempts to answer such a silly question, regardless of what narrow evidence and arguments are used to support the answer, since the question simply cannot be answered.  The challenge is not to try to reach a simplistic yes or no answer, anyway.  It is to study, identify, and promote what does work, and continuously improve the science and art of prevention, and continuously monitor/evaluate how much we can improve it and enjoy as a result.


3 Comments »

  Brian Baum wrote @ August 22nd, 2007 at 9:26 am

On the topic – “Does Prevention Save Money” – I agree completely with your observations. At its core it is a flawed premise and represents an essence of what is wrong with our approach to healthcare. Let’s consider - would a cultural shift in how we look at healthcare as a nation and as individuals from passive to active be a good thing? If individuals were given tools to assist them in more proactively managing their health – in collaboration with their physician – they adopted more healthy lifestyle choices, and they addressed their personal health risk factors – would that be a good thing? Would it save money at a national level – let’s get a team on this right away, let’s study it and get a task force analysis.

Market forces will ultimately resolve this issue. If the market can produce a prevention experience that consumers want and will utilize – everything else falls into place.

In the meantime – we have responded at our blog and as a letter to the editor with specific statistics that address the cost/savings implications of a proactive/preventive health approach. Our response can be found at http://www.mypreventionblog.com/

[…] finally, Scott’s post here on “Does Prevention Saves Money?” garnered this response from Brian Baum: Market forces will ultimately resolve this issue. If […]

  Tripp Wingate wrote @ August 24th, 2007 at 9:04 am

You wrote….”Predictive models can analyze collections of data on past sickness care claims, individual attitudes and behaviors, personality factors and perceptions, as well as on worker productivity and performance, to identify the risk/reward potential of individuals with increasing accuracy. Individualized interventions aimed at multiple risk behaviors or conditions, or at preventing the emergence of such behaviors or conditions, can be generated automatically by computers, and communicated online of via mail for ten or twenty dollars a year per participant.” Do you have references or websites for such applications that exist??? Dr Wingate

Your comment

HTML-Tags:
<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <code> <em> <i> <strike> <strong>